Download I.Ya. HORBACHEVSKY TERNOPIL STATE MEDICAL UNIVERSITY

I.Ya. HORBACHEVSKY TERNOPIL STATE
MEDICAL UNIVERSITY
Disaster medicine and military medicine department
Lecture 2
Cardiac, pulmonary and
cerebral reanimation at prehospital stage

Three stages of ABC-reanimation. Algorithm
of its realization by one and two medical men.
Testimony to defibrillation and technique of its
execution. Cardiac shock of feature of clinical
dynamics, first aid. Acute respiratory
insufficiency. Reasons of origin, types of
hypoxia, degrees of heaviness. Medicinal
therapy. Treatment of post-reanimating illness.
 First
aid at the terminal states.
 Concept about the terminal states,
purpose and task the first medical
aid, first-aid and medical rescue.
 General
principles, legal,
organizational, medical and
deontological features of giving the
first aid in extraordinary situation.
Algorithm of primary inspection of
the patient in the place of event.
BASIC CONCEPTS in
REANIMATOLOGY
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Reanimatology is science about the revival
of organism, which studies etiology,
pathogenesis, diagnostics and treatment of
the terminal states.
A reanimation (abroad widespread is a term
of rescucitation) is a process of replacement
and proceeding in the functions of organism
by the leadthrough of the special
reanimation measures. It is proposed by
V.Negovsky (1975). To these measures a
pneumocardial reanimation belongs in
particular (CLR).

Clinical death -| it is the state which
circulation of blood and spontaneous
breathing absent in the conditions of,
but there yet were irrecurent changes in
the human brain, when it is yet possible
to return a patient to life without a
clinically meaningful neurological
deficit.

Why does attention apply exactly on a
cerebrum? It is a structure of
organism, which most sensible to the
hypoxia or anoxia (clinical death), and
in tissue of which above all things in
case of stopping of circulation of
blood there are irreversible changes.
Maximally this period can last 3-б min,
except of some states, above all things
hypothermias, when vitability of
cortex can be restored and through the
greater interval of time.

Biological death is consisting of
irreversible changes above all things of
CNS, when to life turning a man is
impossible. To the clinical signs of
biological death take drying out and
dimness of cornea, of a corpse spots
and of a corpse окоченіння.
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Such concepts utillize in rescucitation, as a
decortication (social death) is death of cortex
(when somatic functions can recommence almost
in full, but the function of cortex does not
recommence) a that decerebration is death of
cerebrum.
By the clinical signs of decortication ñ absence of
свідомості and purchased reflexes. There is a
timber-toe by the dead bark of the brain on
condition of valuable supervision can live yet long
time. To set the exact diagnosis of decortication
heavily, as there are events, when after the
protracted comma a man came to consciousness.
A
decerebration arises up after more
protracted total ischemia of brain (20
min and anymore), sometimes can
develop on a background a
decortication in the case of progress of
іschemical-reperfusion defeats.

The clinical signs of death of
cerebrum is absence of electric activity
of cerebrum during ЕЕG-decay, atony,
areflexy, hypothermia, bradicardia,
arterial hypotension, absence of the
independent breathing. The vital
functions of organism at decerebration
may be supported of short duration
time due to the leadthrough of AB and
support of circulation of blood. Such
organism can be utillized as a donor
for transplantation of organs.
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On condition of primary stop of circulation
of blood the spontaneous rhythmic
breathing stopping is not later than in 1 min
as a result of exhaustion of respiratory
center. But the terminal types of breathing
are possible: Cheyn-Stoks, Biott, breathing
by Husping.
After the stop of heart a man loses
consciousness already through 10-15 s due
to exhaustion of power substrates in the
brain, first of all glucosum.
MOST WIDESPREAD REASONS OF
UNEFFECTIVE CIRCULATION OF BLOOD
MYOCARDIAC ISCHEMIA
A myocardial ischemia more frequent all
arises up as a result of violation of
circulation of blood in coronarias
(embolism, spasm). The extreme display of
ischemia is a sharp heart attack of
myocardium. As a result of complete
absence of delivery oxygen there is a sharp
deficit of power substrates to cardiac cells,
above all things ATP.
Activity of cells membrane pumps and
canals, foremost Na+, K+ and Ca++ is
violated. The result of it is an accumulation
in the myocardium Na and Ca with
development of intracellular edema, there is
a considerable intracellular deficit of K+.
The finished goods of metabolism
accumulate in myocardium, foremost C02
and lactat which results in heavy
intracellular acidosis.

It does not follow to forget that the damage
of cardiac cells (and also tissues of brain
and other tissues of an organism) takes a
place and after proceeding in perfusion, is
the so-called syndrome of reperfusion. Its
damaging factors are active free radicals
(above all things, oxygen – super-oxides,
peroxides, ions of hydroxide, peroxinitrate)
on a background diminishing of activity of
the antioxidant system.
Reflex stop of heart

Takes a place foremost as a result of
n.vagus reflexes (from an eye is reflex
of Ashner, trachea, carotis areas, root
of lights, stomach, uterus). It should be
noted that usually the stop of cardiac
activity arises up on a background a
myocardial ischemia, intact
myocardium in default of hypoxia (it
can be respiratory hypoxia, ischemia
and others like that) quickly «avoids»
influence of n.vagus.
TYPES OF STOP OF the HEART
Fibrillation of ventricles
The most widespread type of uneffective
circulation of blood in позалікарняних
terms is all of to 2/3 cases. Reason of
фібриляції of ventricles is violation of
leadthrough of impulses on myocardium of
передсердь and ventricles, and also increase
of excitability of myocardium. To the
factors which are instrumental in the origin
of фібриляції of ventricles, take
intracellular hypokaiemia, total cooling of
organism, mechanical irritations, during
implementation of diagnostic and medical
manipulations.
During fibrillation of ventricles there is a
desynchronization of reductions of myo-fibriles
myocardium with the loss of pumping function of
the heart. On EKG fibrillation of ventricles shows
up alike on a wave the curve of different amplitude
in default of auricle and gastric
complexes.
Unpulsive gastric tachycardia

The most widespread type of uneffective
circulation of blood is in the conditions of
permanent establishment. At unpulsive
gastric tachycardia , without regard to
frequent reduction of ventricles, the
retractiveness of myocardium is
considerably mionectic, that is accompanied
uneffective circulation of blood.
Asystole


Practical absence of electric and mechanical
activity of myocardium. On EKG appears as
an almost straight line
The most frequent reason of asystole is
ischemic heart (IKHS) trouble, it can
develop on a background fibrilation of
ventricles which are an unfavorable
prognostic sign.
Electromechanic dissociation (EMD) and
bradiarythmia with the uneffective
mechanical activity of heart

At the transferred
states electric activity
of heart is stored, but
it is not accompanied
effective reductions of
myocardium. On EKG
discover typical and
off type gastric
complexes with a
different rhythm.
off type gastric complexes at
electromechanical
dissociation
Diagnostics of uneffective
circulation of blood


The element of pneumocardial reanimation
is very important. On timely diagnostics of
stop of circulation of blood a prognosis
depends often.
If in the conditions of permanent
establishment cardio-monitoring is
conducted a patient during the stop of
circulation of blood, on a monitor or on
EKG find out the characteristic signs of stop
of circulation of blood.

But more frequent all
uneffective circulation
of blood is diagnosed
only after clinical
signs. To them
absence of pulse
belongs, foremost, on
central arteries (sleepy
and thigh). The
method of research of
pulse is resulted the
way of palpation.
Research of pulse by means of
palpation on a. carotis
To the early signs of unefficiency of circulation of
blood paralytic mydriasis belongs also: at raising of
overhead eyelid a pupil remains wide and
irresponsive on light



Research of pulse by palpation and estimation of
the state of pupil it is possible to perform
simultaneously.
As already marked higher, the obligatory signs of
uneffective circulation is absence of
consciousness and rhythmic independent
breathing.
Such symptoms, as cyanosys of skin, absence of
tones of heart during auscultation, to the pulse on
peripheral arteries, unnecessarily are the signs of
stop of heart, but can be those symptoms which
need immediate estimation of the state of
PNEUMOCARDIAL
REANIMATION
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Complex of measures which are executed
during the leadthrough of CPR, it is
possible to divide on three basic groups:
base sustentation - after the English letters
of ABC:
A (airway ореn) providing of
communicating of respiratory tracts
B (breeth) artificial respiration
C (сirculation) a massage of heart



Must be conducted any man which is alongside;
subsequent methods of CPR, the purpose of
which is proceeding in independent circulation of
blood for a patient: electric дефібриляція,
medicinal therapy;
stabilizing of basic vitally important functions of
organism sick, above all things it touches activity
of cerebrum, heart and vessels, intensive therapy.
If a patient is in the swoon state
(absence of reaction on asking and
mechanical irritation), it is necessary to
perform the followings actions:
 To cause the brigade of medical firstaid, if there is possibility (it is better) reanimation brigade.
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Immediately to begin the leadthrough of
reanimation measures:
1) to provide communicating of respiratory tracts;
2)to check up the presence of the independent
breathing;
3)if the independent breathing absents is a
leadthrough of AB;
4)to define a pulse on a carotid; if during 5 sec to
discover the pulse is impossible - immediately to begin
the non-direct massage of the heart.
Reanimation specialized measures in obedience to
algorithms are performed by reanimation brigade.
Providing of communicating of respiratory tracts

A patient at stop of
circulation of blood
has a presence of
extraneous bodies
reasons of violation of
communicating of
respiratory tracts in the
cavity of mouth and
swallow; supra-larynx
and the root of tongue
is recovered included
in a larynx
Violation of communicating of
overhead respiratory tracts in event
of stopping of circulation of blood

For providing of communicating of
respiratory tracts of patient inlay on a
hard even surface, lying on the back.
After it oral cavity of patient with a gauze
tampon, serviette or handkerchief, release
a finger from blood, vomit the masses,
extraneous bodies (dentures and others
like that). For the leadthrough of rest
room of oral cavity it is possible to apply
an aspirator.
The next stage is
providing of
communicating of
larynx. As a result of
that a tongue is
anatomically related
to the lower jaw, it is
necessary to show out
a lower jaw how it is
indicated on a figure
Variants of leading-out of lower
jaw for proceeding in
communicating of overhead
respiratory tracts


All of medical workers must own this
reception. More simple and less effective,
but made to order to application unmedical
personnel, there is a reception of filling up
of the head.
For this purpose reanimator lays the palm of
one hand on the brow of patient, and долоню of other hand underlays under a neck
and unbends the head simultaneous motion
of both hands (triple reception by Safar).

More professional
methods of
providing of
communicating
of respiratory
tracts is
intubation of
trachea, use of
laringeal mask or
combined airtube - combitube
Laringeal mask
Intubation of trachea is the most reliable method of
providing of communicating of respiratory tracts,
but it must do it professional which will be able to
execute manipulation in short period (30-40 s).
Urgent methods of artificial
ventilation of lights

The methods of AB can be divided into 2
groups: inciter and expiration.
Unfortunately, the inciter methods of AB,
which almost reproduce the physiology
mechanism of the spontaneous breathing,
did not find the wide use in clinical practice
through some inconveniences and difficult
equipment for their leadthrough.

Today most widespread are expiration
methods of AB (due to insufflation of gas
mixture to lights), from urgent methods it
above all things method «mouth to the
mouth», which consists in insufflation of air
in the respiratory tracts of patient under
time of breathing out reanimator. For this
purpose reanimator destroys the lower jaw
of patient up to the top, whereupon densely
takes by his lips the lip of patient and does
exhalation, but necessarily here stops up the
nose of patient.

If the leadthrough of
AB is uneffective (what
absence of excursion
of thorax testifies to),
it is needed to suspect
the presence of
extraneous body in
lower respiratory tracts
(below vocal
connection). At that
rate it follows to use
reception by Geymlikh
– under-diaphragmatic
shove
MAINTENANCE OF CIRCULATION OF BLOOD

Except for providing of adequate
receipt of oxygen in teethridges, it is
needed to provide artificial circulation
of blood. On condition of uneffective
spontaneous circulation apply the
indirect (external) and direct (internal)
massage of heart to that end.-
Indirect massage of heart


A method is based on the
compression of ventricles
of heart between sternum
and and column.
Circulation the leadthrough
of the external massage of
heart provided due to two
mechanisms: to the effect of
pectoral pump and direct
compression of ventricles
of heart, that is why more
expedient would be to talk
about the massage of
thorax.


Reanimator becomes from one
side from a patient, places basis
of one palm on middle part of
sternum approximately on 2
fingers higher from to basis of
sworden out-growth and along
brest-bone disposes the second
palm.
Then by direct hands, not
bending them in elbow joints
(it saves forces), reanimator
executes pressure on sternum
on a depth 4-6 sm for adults.

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For children method of leadthrough of
indirect massage of heart some other. It
consists in pressure one or by two fingers on
sternum with frequency for children junior
in 1 over 100 times per 1 min.
The skilled conducted is closed the massage
of heart enables keeping of systole BP at
the level of 60-80 mm of Hg, although
diastole BP leaves at low level which
diminishes coronal and cerebral perfusion
considerably, and it worsens a prognosis
considerably.

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Reasons of unefficiency of the closed
massage of heart can be hypovolemy,
hemopericarditis, anatomic defects of
thorax.
It should be remembered that during the
leadthrough of the closed massage of heart
it is impossible to do the protracted (over 510 s) pauses.
Many thanks!